Discussion
Children can carry the heaviest burden of viral respiratory diseases.
However, corona virus related infections also vary widely among
pediatric individuals. Studies from China and America recommend, that
children with COVID-19 might be less serious than in adults and that
pediatric cases might knowledge various symptoms than do adults (19,
20); nevertheless, disease characteristics among pediatric patients in
the Turkey have not been described. The aim of this study was
to determine the epidemiological characteristics of pediatric COVID-19
patients during the first 3 months (April - June) of the disease that
occur in Turkey.
Our study included positive pediatric cases confirmed with the RT-PCR
method. The male/female ratio in COVID-19 varies between studies. In
previous reports from China and America, boy outnumbered girls (11, 19-
21). The present study showed a male (51.4%) predominance, similar to
what has been described in the Chinese and American populations (22-24).
In previous studies, ages ranged between 1 day and 18 years (19, 20,
22). In our study, the mean age of the patients was 108.64±65.61 months
and the age range of patients is between 45 days to 18 years. These
results suggests that all ages of childhood were sensitive to COVID-19.
In a Chinese study, the most common symptoms in children with COVID-19
were reported as fever and dry cough (36%, 19%, respectively) (22).
Also in an another previous large-scale study, fever and cough were
reported more frequently in pediatric COVID-19 cases (56%, 54%,
respectively), too. In our study, the most common symptoms on admission
were cough (16.2%), fever (15.2%), lassitude and fatigue (13.3%). In
American study the frequency of sore throat, headache, and diarrhea have
been found to be quite less in pediatric patients (20). The present
study found the symptoms including; sore throat, headache, diarrhea,
loss of taste, anosmia and vomiting (8%, 20%, 4%, 2%, 3% and 6%
respectively). These findings are in line with other studies from other
countries. These results suggests that children do not always have fever
or cough as reported signs and symptoms.
Comorbidities were present in 3.8% of the patients. The comorbidities
were as follows: diabetes mellitus, beta thalasemia major, chronic
respiratory disease, Down syndrome, acute lymphoblastic leukemia and
epilepsy (25).
A 17-year-old girl with insulin-dependent type one diabetes (HbA1C: 8.6)
and bone marrow transplantation due to beta thalassemia major and who
developed bronchiolitis obliterans presented to the emergency department
with shortness of breath and two weeks of a cough. On physical
examination, there was tachycardia and high fever. Also, there was
bilateral crepitan ral and roncus in auscultation. Laboratory workup was
significant for white blood count (WBC) of 7.74 × 103/μL with 0.99 %
eosinophils, blood glucose of 220 mg/dL, elevated C-reactive protein,
and normal venous blood gas. Initial blood and sputum cultures with gram
stain were negative. Computed tomography (CT) of the chest showed ground
glass, peribronchial consolidation areas and mosaic pattern in both
lungs (Fig. 3 ). Despite initial treatment with oseltamivir,
azithromycin and hydroxychloroquine treatment, the patient developed
respiratory distress, so that lopinavir–ritonavir and favipiravir were
added to the treatment. The PCR tests for SARS-COV-2 on the 9th and 11th
days of treatment were negative. The patient was discharged on the 17th
day with healin.
A 6-month-old male patient infected with COVID-19 in April 2020, while
receiving Hemophagocytic Lymphohistiocytosis (HLH) 2004 chemotherapy
protocol with the diagnosis of familial (Genetic / Primary) HLH. In our
patient, which was accompanied by defective perforin gene defect in
primary HLH pathogenesis, COVID-19 infection with the presence of fever
and hyperferritinemia, was evaluated in favor of reactivation and the
patient was given both the HLH-2004 chemotherapy protocol treatment and
COVID-19 therapy as recommended by the guidelines. Our patient improved
clinically and in terms of laboratory test results at the end of the
15-day hospitalization period and was discharged. It should be
remembered that COVID-19 can be seen with different clinical
manifestations in the pediatric age group, and COVID-19 test should be
recommended, especially in children with immunosuppression and fever.
In a previous report covering 2135 pediatric patients with COVID-19, the
disease followed an asymptomatic, mild, moderate, severe and critical.
Regarding the severity, 4.4%, 51.0%, and 38.7% cases were diagnosed
as asymptomatic, mild, or moderate, respectively (totally 94.1% of all
cases) (19). In another study found that children with COVID-19 had
milder clinical manifestations and nearly half of pediatric patients
were asymptomatic (22). In our study, 56.2 % of the cases were
asymptomatic, 30.5% were mild, 10.5% were moderate, 2.9 % were severe
and none of our patients were critical. The percentage of the patients
requiring ICU admission was 2.9%.
Laboratory findings in pediatric COVID-19 patients are generally similar
to those in other coronavirus infections. The number of white cells is
often normal or low; neutropenia and / or lymphopenia may accompany.
Thrombocytopenia may develop. C reactive protein and procalcitonin
values are generally normal. In severe cases, liver enzymes and lactate
dehydrogenase may increase, and abnormal coagulation and high D-dimer
levels have been reported in these cases (26). In our study, we found
the elevated level of lactate dehydrogenase and D-dimer in 3 cases with
severe disease.
Thoracic tomography findings in children are bilateral multiple patchy,
nodular ground glass opacities and / or infiltrations in the middle and
outer zones of the lung or under the pleura. In the present study,
pulmonary ground glass opacities (n = 11, 10.4%) were found as the most
common finding in chest tomography. Other common findings were; local
patchy shadow (n=5, 4.7%) and bilateral patchy shadow (n=4, 3.8%),
respectively. In one of our patients, pleural effusion was seen. These
results are consistent with other reports (11, 21, 27). The radiological
findings are non-specific and milder than adults (17, 21, 27, 28).
To date, there are no published controlled clinical trials on pediatric
COVID-19 specific drug therapy. As with other age groups, there is
insufficient evidence for any drug that can be used in the treatment of
COVID-19 in children. Therefore, suggested treatments for COVID-19 in
child patients should be evaluated in accordance with the studies on
adults and should be planned in specific to a child patient. World
Health Organization and the American Center for Disease Control and
Prevention does not recommend a specific drug for the treatment of
children with COVID-19 (29, 30). In our country, the management of
pediatric patients with COVID-19 is also evaluated by the Scientific
Board of Ministry of Health at frequent intervals and revisions are made
(31, 32). Probable adverse effects of drugs must be taken into
consideration in the decision for treatment in child patients. Treatment
should be evaluated in specific to each child patient, and medication
may be planned for patients with probable severe pneumonia and mild
cases with risk factor. Medicines used in the treatment of patients,
respectively; azithromycin (n = 42, 40%), hydroxychloroquin (n = 21,
20%), empirical antibiotic (n=10, 9.5%), oseltamivir (n = 8, 7.6%),
lopinavir-ritonavir (n = 4, 3.8%) and Favipiravir (n = 1, 0.9%). Only
3 patients needed oxygen therapy. High flow humidified oxygen was
applied to a patient who was followed up in the intensive care unit.
There were some limitations to our study. First, this study was
hospital-based, second it is possible the data may be incomplete and
incorrect due to the retrospective study design.